THE "ON CALL" SERVICE OFFERED BY THE DEPARTMENT OF ANAESTHESIA, MANCHESTER ROYAL INFIRMARY

The "on-call" service offered by the Department of Anaesthesia,Manchester Royal Infirmary was studied in December 1981. Thereasons for any delay in service were analysed and suggestionsfor improvement discussed. ^*Present address: Main Theatre, Hope Hospital, Eccles Old Road,Salford     

Long‐Term Randomized Trial of Intensive Versus Symptomatic Management in Paget's Disease of Bone: The PRISM‐EZ Study

It has been suggested that normalization of bone turnover may improve clinical outcome in Paget's disease of bone (PDB) by preventing complications such as fractures and the development of osteoarthritis. Here we investigated the long‐term effects of a treatment strategy that aimed to normalize bone turnover in PDB with that of symptomatic treatment. The study group comprised 502 subjects who were enrolled into a 3‐year extension of the Paget's Disease: Randomized Trial of Intensive versus Symptomatic Management (PRISM) study. Intensive bisphosphonate therapy was continued in 270 of these subjects with the aim of normalizing bone turnover using zoledronic acid as the treatment of first choice. Symptomatic treatment continued in 232 subjects in whom bisphosphonates were only given for the treatment of bone pain. The primary outcome was fracture and secondary outcomes were orthopedic procedures, quality of life, and bone pain, adjusted for baseline characteristics. Serum total alkaline phosphatase (ALP) concentrations were significantly lower in the intensive group on entry to the study and the differences between groups increased as the study progressed. There were no clinically important differences in quality of life measures or bone pain between the treatment groups. Intensive treatment was associated with a nonsignificant increase in fracture risk (hazard ratio = 1.90; 95% CI, 0.91 to 3.98; p = 0.087), orthopedic procedures (1.81; 95% CI, 0.71 to 4.61; p = 0.214), and serious adverse events (relative risk 1.28; 95% CI, 0.96 to 1.42). We conclude that long‐term intensive bisphosphonate therapy confers no clinical benefit over symptomatic therapy and is associated with a nonsignificant increase in the risk of fractures, orthopedic events, and serious adverse events. The results of this study suggest that in patients with established PDB, bisphosphonate therapy should focus on control of symptoms rather than suppression of bone turnover. © 2016 American Society for Bone and Mineral Research.     

A comparison of the academic impact of plastic surgery units in the United Kingdom and Ireland using bibliometric analysis

Academic output is just one aspect of a successful career as a plastic surgeon. However, for those with a strong interest in academia, the academic output of a department will likely be a key factor when deciding how to rank jobs. The aim of this study was to quantify and rank the academic output of plastic surgery units across the UK and Ireland. The Institute for Scientific Information (ISI) Web of Science Bibliometric analysis tool was used to collate cumulative (1950–2016), 10 year (2006–2016) and 3 years (2013–2015) research output data for plastic surgery units in the UK and Ireland. Sixty-six plastic surgery units were identified. Departments were ranked for each time period according to the number of papers produced, number of citations (Nc) and h-index (a measure of the impact of scientific output). The top 3 departments for number of papers in the last 10 years were The Royal Free Hospital, London (226) Broomfield Hospital, Chelmsford (218), and Morriston Hospital and Swansea (188). The top 3 for h-number were The Royal Free Hospital (21) Wythenshawe Hospital, Manchester (18) and Morriston Hospital (17). Academic output varies across plastic surgery units in the UK and Ireland. A number of departments have consistently maintained high academic outputs across the years and will be of interest to surgeons hoping to pursue a career in academia.     

Audiovisual reviews

Central venous pressure measurement By G.D. P arbrook , P.O. D avis and E.O. P arbrook (Royal Infirmary, Glasgow).
Nerve blocks around the knee By K. B rown (Royal Children's Hospital, Melbourne).
Ankle blocks By K. B rown (Educational Resource Centre, Royal Children's Hospital, Melbourne).
Blocks for common paediatric operations By K. B rown (Education Resource Centre, Royal Children's Hospital, Melbourne).
Lower limb nerve blocks By K. B rown (Educational Resource Centre, Royal Children's Hospital, Melbourne).
Lumbar sympathetic block By K. B rown and J. M adden ( Royal Children's Hospital, Melbourne ).
Burns—nerve blocks of the thigh By K. B rown and C. R eardon ( Educational Resource Centre, Royal Children's Hospital, Melbourne ).
Anaesthesia for children By K. B rown and T. S koroplas (Royal Children's Hospital, Melbourne).     

EFFECTS OF ANAESTHETIC TECHNIQUE ON DEEP VEIN THROMBOSIS: A Comparison of Subarachnoid and General Anaesthesia

Forty patients with fractured neck of femur were allocated randomlyto undergo surgery under general anaesthesia (GA) or subarachnoidanaesthesia (SAB). After operation, the incidence of deep veinthrombosis (DVT), assessed by venography, was found to be 40%in the SAB group, which was significantly lower than the incidence(76.2%) in the GA group. These observations may account forthe previously reported effect of SAB, in comparison with GA,in reducing early postoperative mortality in this category ofpatient. ^*Nuffield Department of Anaesthetics, Radcliffe Infirmary,OxfordOX2 6HE. Department of Orthopaedic Surgery, Royal Liverpool Hospital,LiverpoolL7 8XP. University Department of Anaesthesia, Leicester Royal Infirmary,Leicester LEI 5WW.     

Sudden onset of back pain

Summary Patients attending a back pain clinic completed a structured interview, with particular reference to whether onset of the first episode of back pain was sudden or insidious. They were classified into four diagnostic groups. A significantly higher proportion of patients who had experienced a sudden onset of pain suffered from sciatic pain with positive root tension signs than was the case with patients whose pain had started more insidiously (50.8% vs. 20.6%; P<0.001). These patients were also more likely to be male, to have been lifting or twisting with a weight, and to have been confined to bed or hospitalised, and have undergone manipulations, than patients with insidious onset of their pain.Research was carried out at the Department of Orthopaedics, Royal Infirmary, Doncaster, UK     

Familial Paget Disease and <Emphasis Type="Italic">SQSTM1</Emphasis> Mutations in New Zealand

Genetic factors play an important role in the pathogenesis of Paget disease of bone (PDB). SQSTM1 is the most important disease-associated gene identified to date. We investigated the relationship of family history, phenotype, and SQSTM1 mutation status in New Zealand (a country with a high prevalence of PDB) in patients with a family history and/or a severe phenotype. We studied 61 unrelated subjects with familial PDB. Family history was subclassified into three groups according to the closeness of the relationship. We also studied a fourth group of 19 unrelated patients defined by early onset and/or severe disease but no family history. The PDB phenotype was defined according to age, alkaline phosphatase activity, and disease extent on scintiscan at the time of diagnosis. Mutations in exon 8 of SQSTM1 were detected by screening of genomic DNA. Four different mutations were identified; the ubiquitous P392L mutation and the truncating mutation E396X accounted for 89% of cases. Overall 26% of patients with familial PBD in New Zealand had disease-associated mutations in the SQSTM1 gene. Mutations were most prevalent (60%) in those with a parent or sibling and at least one other relative affected (P < 0.002). The severity of the phenotype was significantly related to SQSTM1 mutation status but not the strength of the family history (P < 0.005). SQSTM1 mutations were found in 10.5% of patients with early onset and/or severe disease but no family history.     

Vascular surgical audit-arterial reconstructions and amputations for lower limb ischaemia

There were 750 arterial reconstructions and 2134 major amputations in hospitals within the South West Regional Health Authority (SWRHA) from 1974-1978, according to a Hospital Activity Analysis (HAA) based survey of all patients undergoing these operations for atherosclerotic limb ischaemia. Those undergoing arterial reconstruction fared better than amputees in terms of hospital mortality (5.2% vs. 21%) and length of hospital stay (21.4 days vs. 47 days). Comparison of the HAA results with case records and operating theatre books at Bristol Royal Infirmary showed a failure-of-inclusion rate of 10% for arterial reconstructions and 9.3% for amputations. There was a difference in the proportion of arterial reconstructions to major amputations (2.5:1) at Bristol Royal Infirmary compared with SWRHA hospitals (1:3), but hospital stay and operative mortality were similar.     

Comparison of volume displacement versus circumferential arm measurements for lymphoedema: implications for the SNAC trial

Background: The Royal Australasian College of Surgeons Sentinel Node versus Axillary Clearance trial is a randomized controlled trial comparing sentinel node biopsy with axillary clearance in breast cancer patients. Primary study end‐points include arm volume differences with time, which may indicate the development of lymphoedema. The RACS SNAC trial uses circumferential arm measurements in the estimation of arm volume. This study aimed to assess the accuracy of circumferential volume estimation in comparison with water displacement. Methods: Eighty‐seven women attending the breast clinic at the Women’s Health Centre, Royal Adelaide Hospital, were assessed by volumetric and circumferential arm measurements. Correlations between volume estimations and measurements were made, taking into account the width of measuring tape and body mass index. Results: There was a highly significant correlation between circumferential and volumetric arm measurements (Pearson’s correlation coefficient = 0.92, P < 0.0001), especially when using the narrow measuring tape. Correlation was best in the overweight BMI group (Pearson’s correlation coefficient = 0.94. P < 0.0001) and worst in the obese group (Pearson’s correlation coefficient = 0.79, P < 0.0001) but all relationships were statistically significant. Conclusion: Using a narrow tape, circumferential arm measurement is an appropriate method for assessing arm volume in the SNAC trial.     

Feedback

We received correspondence from Dr Bruce Powell of FremantleHospital, Western Australia and Drs Marie Healy and Peter Shirleyof the Royal London Hospital in connection with the articleby John Hunter, Katy Gregg and Zaherali Damani on Rhabdomyolysis(     

EFFECTS OF SUBARACHNOID SPINAL NERVE BLOCK AND ARTERIAL PCO2 ON COLON BLOOD FLOW IN THE DOG

Changes in colon blood flow in greyhounds were measured in responseto acute changes in arterial PCO₂, before and after spinal nerveblock. Colon blood flow increased significantly after spinalnerve block, irrespective of PCO₂. The findings may be of clinicalimportance in man. ^*University Department of Anaesthesia, The General Hospital,Gwendolen Road, Leicester. Department of Surgery, Royal Infirmary, Glasgow. Victoria Infirmary, Glasgow.     

Management of complications of tracheal surgery--a case of dehiscence

We report a case of tracheal stenosis in a patient with immunethrombocytopenia who presented 4 yr after splenectomy. The 20-yrprogression of the stenosis and management, including resection,is charted. The period after resection was complicated by woundinfection, surgical emphysema, mediastinitis and dehiscenceof the anastomosis of the trachea. The management of patientswith tracheal lesions is discussed, but concentrates on airwaycare after tracheal resection when complications developed.A laryngeal mask airway was used to stabilize an uncuffed trachealtube at the site of dehiscence. Footnotes ² Present address: Hull Royal Infirmary, Hull, UK     

Comparing alarms, desmopressin, and combined treatment in Chinese enuretic children

The objective of this multicenter randomized controlled trial was to compare the efficacy of enuresis alarms, oral desmopressin, and combined treatment in Chinese children with monosymptomatic primary nocturnal enuresis. We assigned 105 children aged 7–15 years to receive alarms (group 1, 35 patients), oral desmopressin 400 g (group 2, 38 patients), or combined therapy (group 3, 32 patients) for 12 weeks; patients were then followed for 12 weeks after treatment. The wetting frequency decreased during treatment by 46%, 52%, and 73% in groups 1, 2, and 3, respectively. In groups 2 and 3, but not in group 1, there was rebound post treatment, but significant improvements persisted at 12 weeks. The complete and partial response rates were 22.9% and 20%, respectively in group 1, 42% and 10.5% in group 2, and 62.5% and 15.6% in group 3. By Kaplan-Meier analysis, group 1 had a significantly poorer response than groups 2 and 3. Of the responders, 20%, 60%, and 40% in groups 1, 2, and 3, respectively, relapsed after stopping treatment. In conclusion, enuresis alarms and/or oral desmopressin were less efficacious in Chinese than in Western societies. Desmopressin produced an immediate effect but relapses were common. Alarms took several weeks to produce a benefit, which was persistent on follow-up.This study was carried out by the Hong Kong Childhood Enuresis Study Group. Other members are: Sonia Chang (Kwai Chung Hospital), Stella Chim (Queen Mary Hospital), Man-Chun Chiu (Princess Margaret Hospital), Kwok-Wai Lee (Queen Elizabeth Hospital), Lettie Leung (Kwong Wah Hospital), Kei-Chiu Tse (Princess Margaret Hospital), Esther Wong (Prince of Wales Hospital), Fai-To Yau (Alice Ho Miu Ling Nethersole Hospital), Chung-Kwong Yeung (Prince of Wales Hospital), and Pa-Shing Yeung (Caritas Medical Center)     

First update of the International Xenotransplantation Association consensus statement on conditions for undertaking clinical trials of porcine islet products in type 1 diabetes—Chapter 4: pre‐clinical efficacy and complication data required to justify a clinical trial

In 2009, the International Xenotransplantation Association (IXA) published a consensus document that provided guidelines and “recommendations” (not regulations) for those contemplating clinical trials of porcine islet transplantation. These guidelines included the IXA's opinion on what constituted “rigorous pre‐clinical studies using the most relevant animal models” and were based on “non‐human primate testing.” We now report our discussion following a careful review of the 2009 guidelines as they relate to pre‐clinical testing. In summary, we do not believe there is a need to greatly modify the conclusions and recommendations of the original consensus document. Pre‐clinical studies should be sufficiently rigorous to provide optimism that a clinical trial is likely to be safe and has a realistic chance of success, but need not be so demanding that success might only be achieved by very prolonged experimentation, as this would not be in the interests of patients whose quality of life might benefit immensely from a successful islet xenotransplant. We believe these guidelines will be of benefit to both investigators planning a clinical trial and to institutions and regulatory authorities considering a proposal for a clinical trial. In addition, we suggest consideration should be given to establishing an IXA Clinical Trial Advisory Committee that would be available to advise (but not regulate) researchers considering initiating a clinical trial of xenotransplantation.     

Non‐contact low‐frequency ultrasound therapy compared with UK standard of care for venous leg ulcers: a single‐centre,assessor‐blinded,randomised controlled trial

‘Hard‐to‐heal’ wounds are those which fail to heal with standard therapy in an orderly and timely manner and may warrant the use of advanced treatments such as non‐contact low‐frequency ultrasound (NLFU) therapy. This evaluator‐blinded, single‐site, randomised controlled trial, compared NLFU in addition to UK standard of care [SOC: (NLFU + SOC)] three times a week, with SOC alone at least once a week. Patients with chronic venous leg ulcers were eligible to participate. All 36 randomised patients completed treatment (17 NLFU + SOC, 19 SOC), and baseline demographics were comparable between groups. NLFU + SOC patients showed a −47% (SD: 38%) change in wound area; SOC, −39% (38%) change; and difference, −7·4% [95% confidence intervals (CIs) −33·4–18·6; P = 0·565]. The median number of infections per patient was two in both arms of the study and change in quality of life (QoL) scores was not significant (P = 0·490). NLFU + SOC patients reported a substantial mean (SD) reduction in pain score of −14·4 (14·9) points, SOC patients' pain scores reduced by −5·3 (14·8); the difference was −9·1 (P = 0·078). Results demonstrated the importance of high‐quality wound care. Outcome measures favoured NLFU + SOC over SOC, but the differences were not statistically significant. A larger sample size and longer follow‐up may reveal NLFU‐related improvements not identified in this study.     

An Analysis of the Predictability of Hypoxemia Following Vertical Banded Gastroplasty

Postoperative (post-op) hypoxemia is unpredictable, often undetected by physical examination, sometimes fatal. We studied 45 morbidly obese patients with an average age of 37, including 16 smokers, having vertical banded gastroplasty (VBG) for useful preoperative (pre-op) predictor(s) of post-op hypoxemia during the first five days following VBG. Patient blood gases (arterial blood oxygen, P_aO₂, in mmHg), pre-op and five post-op days (POD), after 30 min in room air were: pre-op, 85 ± 9; POD1, 63 ± 9*; POD2, 61 ± 9*; POD3, 63 ± 10*; POD4, 63 ± 9*; POD5, 64 ± 11*. (*p < 0.05, Student's t-test compared with pre-op). Linear regression showed no practical, predictive value for P_aO₂ for age, Body Mass Index (BMI), pulmonary function tests (PFTs), smokers or preop P_aO₂. Post-op atelectasis occurred in 84% of patients, mostly the posterior basilar regions on chest X-ray. No patient developed clinically diagnostic pneumonia. VBG patients experienced profound hypoxemia post-op, the lowest on POD2. There is no reliable method to predict which patient may develop severe hypoxemia. It is, therefore, extremely helpful to uniformly monitor P_aO₂ post-op in morbidly obese patients.     

The Immediate Management of the Patient with Rupture: Open Versus Endovascular Repair (IMPROVE) Aneurysm Trial-ISRCTN 48334791 IMPROVE trialists

Background: Systematic reviews have suggested a survival advantage for patients with ruptured abdominal aortic aneurysm (AAA), who are managed by endovascular repair. These reviews are based on single centre experiences of selected patients.

Objective: To determine whether a policy of endovascular repair improves the survival of all patients with ruptured AAA.

Methods: A randomized controlled trial, IMPROVE (ISRCTN 48334791) will randomize patients with a clinical diagnosis of rAAA, made in hospital, either to immediate CT scan and endovascular repair whenever anatomically suitable (endovascular first), or to open repair, with CT scan being optional (normal care), The trial is set on a background of guidelines for emergency care, CT scanning and anaesthesia, which incorporate the protocol of permissive hypotension. Recruitment started in October 2009 and 600 patients are required to show a 14% survival benefit at 30 days (primary outcome) for the endovascular first policy. Recruitment will be from the UK and Europe. Secondary outcomes include 24h, in-hospital and 1 year survival, complications, major morbidities, costs and quality of life. Discussion: This is a “real life” trial that will answer the fundamental relevant clinical dilemma, namely, do patients who present with ruptured AAA derive benefit from treatment in a system, which offers a preferential strategy of endovascular repair ? The trial addresses whether the anticipated reduced mortality and morbidity associated with endovascular repair is offset by the relatively greater ease of access and speed to conventional surgery. This issue is pivotal to future patient care and provision of services.     

Influence of sex on expansion rate of abdominal aortic aneurysms

BACKGROUND: The UK Small Aneurysm Trial suggested that female sex is an independent risk factor for rupture of abdominal aortic aneurysm (AAA). This study assessed the effect of sex on the growth rate of AAA. METHODS: Between January 1985 and August 2005 all patients who were referred to the Royal Infirmary of Edinburgh with an AAA who were not considered for early aneurysm repair were assessed by serial abdominal ultrasonography. Maximum anteroposterior and transverse diameters of the AAAs were measured. RESULTS: A total of 1255 patients (824 men and 431 women) were followed up for a median of 30 (range 6-185) months. A median of six examinations (range 2-37) was performed for each patient. Median diameter on initial examination was 41 (range 25-83) mm. Median growth rate overall was 2.79 (range - 4.80-37.02) mm per year. Median growth rate of AAA was significantly greater in women than men (3.67 (range - 1.2-37.02) versus 2.03 (range - 4.80-21.00) mm per year; P < 0.01). Weighted linear regression analysis revealed that large initial anteroposterior AAA diameter and female sex were significant predictors of faster aneurysm growth rate (P < 0.001 and P = 0.006 respectively). CONCLUSION: The growth rate of AAA was significantly greater in women than in men. This may have implications for the frequency of follow-up and timing of repair of AAA in women.     

ABDOMINAL WOUND PERFUSION FOR THE RELIEF OF POSTOPERATIVE PAIN

In a double-blind trial, 50 patients with subcostal incisionsperformed for cholecystectomy or splenectomy, received 10 mlofeither 0. 5% bupi-vacaine plain or physiological saline twicedaily by woundperfusion through an indwelling drainage tubefor 3 days after operation. Analgesia, assessed by visual analoguescore (VAS) and forced vital capacity (FVC), was significantlyimproved after perfusion with bupivacaine. Perfusion with physiologicalsaline produced an analgesic effect comparable to that of bupivacaineas indicated by improvement in VAS. There was, however, no improvementin FVC, and opioid requirements were greater, in the patientswhose wounds had been perfused with saline. ^*Department of Anaesthetics, Royal Infirmary, Edinburgh. Plastic Surgery Unit, Canniesburn Hospital, Glasgow.     

COMPLICATIONS OF TRACHEOTOMY

A patient underwent elective tracheotomy before resection ofthe floor of the mouth. After operation, several life-threateningcomplications arose from this tracheotomy, including surgicalemphysema of the tracheal mucosa which has not been describedpreviously. (Br. J. Anaesth. 1993; 71: 898–901) ^*Division of Anaesthesia, Royal Infirmary, Glasgow, G31 3ER St John's Hospital at Howden, Howden West, Livingston, WestLothian EH54 6PP